ORIGINAL ARTICLE
SUMMARY
Objective: To progress in the understanding of the user proile and of search trends for health information on the internet. Methods: Analyses were performed based on 1,828 individuals who completed an electronic questionnaire available on a very popular health website. At the same time, through the “elite survey” method, 20 specialists were interviewed, aiming at assessing quality control strategies regarding health information disseminated online. Results: A predominance of female users who research informa-tion for themselves (≈ 90%), who consider the internet one of their main sources of health information (86%), and who spend from 5 to 35 hours online every week (62%) was veriied. High reliability is assigned to information from specialists (76%), and low reliability to television, radio, or blogs (14%). Conclusion: It can be concluded that the internet is proving to be a major source of health information for the population, and that website certiication is a strategy to be contemplated to improve the quality of infor-mation and to promote public health.
Keywords: Health communication; internet; public health; information search behavior. ©2012 Elsevier Editora Ltda. All rights reserved.
Study conducted at the Universidade Federal de
São Paulo, São Paulo, SP, Brazil
Submitted on: 02/29/2012
Approved on: 07/01/2012
Correspondence to: Felipe Azevedo Moretti Rua Pedro de Toledo, 598
Vila Clementino CEP: 04039-001 São Paulo, SP, Brazil Phone/Fax: +55 (11) 5575-2970 + 55 (11) 5085-0248 felipe.moretti@unifesp.br
Conflict of interest: None.
Access to health information on the internet: a public health issue?
FELIPE AZEVEDO MORETTI1, VANESSA ELIASDE OLIVEIRA2, EDINA MARIKO KOGADA SILVA3
1 Undergraduate Degree in Physiotherapy; MBA in Economy and Health Management, Universidade Federal de São Paulo (UNIFESP); Student, Postgraduate Course, Internal Medicine
and Therapeutics Program, UNIFESP; Responsible for the Project Cochrane Consumidores do Brasil, São Paulo, SP, Brazil
2 MSc and PhD in Political Sciences, Universidade de São Paulo (USP); MSc in Public Health, Faculdade de Ciências Médicas da Santa Casa de São Paulo; Professor of Political
Sciences and Public Politics, Universidade Federal do ABC, São Paulo, SP, Brazil
INTRODUCTION
Research indicates that by 2001, approximately 52 mil-lion Americans had already searched the internet for medical information, and that the internet is the main source of health information for 70% of U.S. adults1,2.
In Brazil, it is estimated that over 10 million users ac-cess health websites on a regular basis3. he commercial
use of the internet in the country began in 1995 and, as in other countries, there was a rapid growth in the sub-sequent years. Between September, 2000 and Septem-ber, 2002, the number of internet users in Brazil grew by more than 50%4. At the time, there were 7.68 million
active users in households. Taking into accounting the number of individuals accessing the internet at work, at cyber cafés, or at friends’ houses, the total number could reach 22.1 million5. hese numbers have increased
signiicantly over the last few years. In 2009, 67.9 mil-lion people aged over 10 years old reported to have used the internet, which represents an increase of 12 million (21.5%) over 2008 – according to the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geo-graia e Estatística – IBGE)6. Soaresalso points out that
the Brazilian citizen is the world leader on average time spent on the internet5.
Researches show that the creation of the internet has signiicantly promoted access to information and has also collaborated with mass production of content from several sources7. In the healthcare ield, interaction
through the internet – which enables the exchange of ex-periences between patients with similar problems, and makes discussion between experts and patients easier – was identiied as a powerful strategy to manage several clinical conditions8, providing improvements in users’
quality of life by promoting greater autonomy, pro-ac-tivity, and self-conidence among participants. here are other beneits, such as improvement in social interaction and learning, reduction of hopelessness, better coping with life situations, more knowledge about the disease, emotional relief, and clinical improvement9-11.
However, as any means of communication, the in-ternet presents its recalcitrances, its singularities, and its biases, thus it is necessary to use this instrument for obtaining information carefully. As Biruel7 stated: “he
internet can represent a great risk in the healthcare ield, as both healthcare professionals and consumers may not be aware of the rules regarding the identiication of qual-ity standards.”
Several experts point out that the majority of infor-mation about diseases and treatments available on the internet is scientiically inadequate or incomplete12–14.
Facing this reality, authors suggest that health web-sites should use compliance certiication seals granted through criteria established by specialized organizations.
his is one form of ensuring a quality standard for infor-mation disseminated on the web.
In addition, studies show a trend of health websites grow-ing in number faster than the overall use of the internet4.
Despite the relevance that the internet has gained in terms of access to health information, Soares5 points
out that there are few studies about the Brazilian reality in terms of internet use for health purposes. In this re-gard, speciic research or interventions, including by the public sector, are important for better understanding the use of the internet for health purposes, its advantages and its risks. Accordingly, it is worth questioning the role of the state and the society in the regulation of how health information is available on the web.
METHODS
In order to better understand the user proile and search trends for health care information on the internet, the authors opted for a cross-sectional study. An electronic questionnaire was prepared for data collection, with questions regarding the performance of searches for health care information, level of trust in the information retrieved, number of hours spent on the internet, and users’ socio-economic proile, among others. his ques-tionnaire was made available in a very popular Brazilian health website (4 million accesses/month), Minha Vida. Users were invited to collaborate with this research.
Data were collected between January and February, 2011. he project was approved by the Ethics and Re-search Committee of the Hospital São Paulo – Universi-dade Federal de São Paulo (UNIFESP) – under number 0434/10, and the participants of the study agreed with the informed consent.
he input and data analysis were made using Mi-crosot Excel®. Data obtained was analyzed through de-scriptive statistics, aiming to characterize a sample and identify stand-out patterns of conduct.
Another stage of the research included a qualitative study, with semi-structured interviews with experts in health communication, who were selected based on the relevance of these agents in the area at stake, pursuant to the “elite survey” method. he objective was to cap-ture the privileged view of principal agents in the area of health communication, who were identiied by reputa-tion criteria and recognireputa-tion of their ability to impact their ield. An elite survey does not have a sampling nature; its main objective is not statistical, and it is ex-tremely useful to understand the evaluations of experi-enced agents in the study area15.
Twenty experts from diferent entities were inter-viewed, among them: FioCruz, Associação Paulista de Saúde Pública, Conselho Regional de Medicina do Es-tado de São Paulo, Secretaria Municipal de Saúde de São Paulo, Biblioteca Virtual de Saúde, Associação Médica Brasileira, Centro Cochrane do Brasil, Universidade Federal de São Paulo, and Public Health Faculty of the Universidade de São Paulo. he number of interviews conducted proved suicient to understand the “mean-ings, symbolic and classiication systems, codes, practic-es, valupractic-es, actions, ideas, and feelings”. hese interviews occurred between October, 2011 and February, 2012.
• he questions at this stage aimed to collect informa-tion on the following aspects:
• Importance of certiication of health websites in Brazil.
• Strategic importance (assigning a score from 0 to 10) of the following institutions regarding certiica-tion (Brazilian Ministry of Health; State Health De-partments; Universities; Medical Associations and Patient Associations).
• Alternative actions to ensure quality of health infor-mation on the internet
• Potential strategic actions to qualify health informa-tion disseminated on the internet
RESULTS
he sample of 1,828 individuals that collaborated with the research showed an user proile seeking information about their own health (90% of the sample) or the health of their family members (79%); there was a predomi-nance of females (89%), and of individuals who use the internet heavily: 62% of interviewees spend 5 to 35 hours on the internet per week, 12% spend more than 35 hours a week, and 42% more than 2 hours a day. For health-speciic searches, 51% do so more than once a week, 59% from two to ten times a month, and 26% over ten times per month (Table 1).
he states with the largest number of people who collaborated with the study were: São Paulo (766 indi-viduals = 46% of the sample), Minas Gerais (183 indivi- duals = 10%), Rio de Janeiro (142 individuals = 8%), Rio Grande do Sul (102 = 6%), Bahia (92 individual = 5%), and Paraná (90 individual = 5%).
Of the 1,828 individuals, 80% answered “yes” to the question: “Do you use the internet as one of your main sources of health information?”
When broadening the question to “What are your main sources of health information?” – more than one answer possible –, the internet shows a frequency of 86%,
against 74% for opinion of physicians or specialists, 50% for information from television or radio, and 39% for health books (Graphic 1).
To assess the level of trust in diferent sources of information, a question listing 11 diferent sources, to which four levels of reliability were assigned, was includ-ed in the questionnaire. he interviewee was requestinclud-ed to assign a level of reliability to each one of the informa-tion means.
Data related to highly reliable sources, as assigned by interviewees, was separated and presented in Table 2.
When analyzing the answers to which low or very low levels of reliability were assigned, the result was almost mirrored, i.e., the information means that presented a low percentage of “highly reliable” answers were the ones that presented the higher indexes of low or very low reli-ability. In this regard, the sources that presented high-er indexes of low or vhigh-ery low reliability whigh-ere non-spe-cialized magazines or newspapers (such as Veja, Isto É, and Época), electronic search engines (such as Google, Yahoo, and Bing), health blogs, and television or radio.
he study population showed a high degree of inter-est in many diferent health topics. High interinter-est was ex-pressed, for example, by at least 50% of the individuals in all subjects researched (quality of life, prevention of health problems, food and diet, causes and symptoms of health problems, medical diagnosis, medical and drug therapies, alternative therapies, and child health). he same trend is observed when studying the degree of in-terest in certain health conditions, such as anxiety, can-cer, and obesity.
Online activities related to health mentioned more frequently by the population in the study were: read-ing of journal articles, search for self-diagnosis, video viewing, blog reading, search for quality of life and diet, search for supplementary information ater medical ad-vices, search for information ater feeling any symptom, and search for alternative therapies.
Regarding actions ater an online search, the most frequent are: talk to friends/family members about the information obtained (70%), lifestyle change (65%), talk to a physician (48%), and schedule a medical appoint-ment (30%).
Conversely, the actions more frequently mentioned as not taken by users are: online purchase of health products or services (51% do not), search for online health professionals or services (45% do not), viewing of online advertisements (35% do not).
Graphic 1 – Sources searched for health information.
I usually do not search for health information on the internet
Digital specialized libraries or websites related to universities
Online newspapers and magazines, or websites such as: Folha, Estado, UOL, Terra etc. Medical associations or other specialized websites
Search engines such as Google, Yahoo, Cadê, Bing etc.
Health websites, such as: Minha Vida, ABC da Saúde, Boa Saúde etc.
0% 20% 40% 60% 80% 100%
he certiication of health websites was deemed a good strategy by communication experts. he aver-age grade (from 0 to 10) assigned to the importance of health websites certiication was 8.2, and the Brazilian Ministry of Health was the most mentioned among the entities that should undertake such task.
Some aspects pointed out during interviews are note-worthy. Firstly, the need to establish a legal framework to regulate health information available on the internet, without interfering in the individual freedom of expres-sion, emerged as a subject to be debated and contemplat-ed. his point can be captured in the statements below:
Data n %
Education
High School degree 483 26%
College degree 459 25%
Incomplete secondary education 362 20%
Post-graduation course fully or partially completed 391 21%
Elementary school fully or partially completed 133 7%
English knowledge
Basic level 737 40%
None 676 37%
Intermediate level 250 14%
Advanced level or fluent 163 9%
Monthly income
Up to R$ 510.00 79 4%
From R$ 510.00 to R$ 1,530.00 509 28%
From R$ 1,530.00 to R$ 3,060.00 564 31%
From R$ 3,060.00 to R$ 5,100.00 361 20%
From R$ 5,100.00 to R$ 10,200.00 222 12%
Over R$ 10,200.00 93 5%
Frequency of SUS (Unified Health System) use
Never 687 38%
Little 540 30%
Sometimes (moderately) 278 15%
Often – it is my main service provider 295 16%
“Health professional councils should work together to establish a legal regulatory framework.”
“We need a public forum for discussion, with ex-change of information and strategies conducted by the Ministry of Health.”
“Monitoring and control of several websites.”
“Creation of working groups to discuss the issue in several health institutions.”
“Promotion of strategic discussions, such as on Twit-ter and Facebook.”
Another aspect highlighted was the possibility of acknowledged and relevant institutions in the ield of public health to take over health websites, ensuring the quality of the information provided:
“Medical schools should patronize health websites, so their content would be certiied.”
“Requirement of a technician in charge with educa-tion corresponding to the informaeduca-tion discussed.”
Finally, another point raised was the need to increase awareness of the issue in society, through processes of social education (e.g., through highly popular TV pro-grams), in order for citizens to become more critical of information easily accessed via the internet:
“Certifying websites is not enough, it is necessary to make users understand this problematic situation better, with more TV programs and lectures on the subject.”
“User education/empowerment and free exchange of information on the subject.”
DISCUSSION
he ease of insertion of several sources of information on varied subjects made the internet a great outreach and search tool in the healthcare ield. Searches vary
from diseases and their treatments to prevention of pa-thologies, promotion of wellness, nutrition, hygiene, and services7.
However, a better understanding of the metrics or patterns of search for healthcare information on the in-ternet is critical, considering that the user of this tool may be exposed to a great amount of dubious and incon-sistent information16. While there is the ease of inding
all sorts of information, conversely, there is the diiculty of obtaining reliable information, as the amount of data makes it diicult to locate a reliable source17.
A research carried out by Google in Brazil18 to
un-derstand the use of the Web for health purposes has shown that the internet is an important channel for re-search on diseases and treatments. he study was per-formed with 603 Brazilian adults that had searched the internet for diseases, medications, and health questions in general during the previous three months. he study stated that the sample proile was representative of the universe of internet users in Brazil. In this research, the main topic researched by interviewers was medical treatment (60%), followed by general information about diseases (52%), causes and symptoms (48%), informa-tion about medicainforma-tions (40%), potential treatment con-sequences (39%), search for specialists (39%), and diag-nosis of diseases (28%). Searches related to nutrition and diet, itness, and child health were also mentioned with high prevalence.
Of the more frequent online activities, the reading of articles was reported by 78% of the 603 interviewees, 35% said they read blogs, and 30% oten saw or clicked on ads, made self-diagnostic tests, watches videos, and posted comments in blogs.
Source of information Highly reliable
Physicians’, healthcare professionals’, or specialists’ opinion 76%
Books on health 55%
Journal articles 52%
Medical associations or other specialized websites 51%
Health websites, such as: Minha Vida, ABC da Saúde, Boa Saúde etc. 47%
Digital specialized libraries or websites related to universities 45%
Online newspapers and magazines, or websites such as: Folha, Estado, UOL, Terra etc. 20%
Television or radio 18%
Non-specialized magazines or newspapers, such as: Veja, Isto é, Época etc. 16%
Websites derived from electronic search engines as Google, Yahoo etc. 12%
Blogs on health 10%
Many of the data presented in the Google study are close to or match the indings of the present research.
Also on the Google study, 85% of the sample said they used search engines such as Yahoo, Cadê, and Google to search for issues related to healthcare and medications; the use of simple search engines is the main online source of information. Among traditional (oline) sources, the most used are healthcare professionals (57%), magazines (53%), books (42%), television (40%), package inserts (33%), and newspapers (28%).
Simple search engines also appear as the most useful source of information about healthcare issues, preferred by 42% of the sample, followed by healthcare profes-sionals (14%). Additionally, 72% of the sample indicated search engines as the irst source of information about healthcare, followed by experts, with 44%, and websites or wellness magazines, with 31%.
Interviewees airmed to spend, on average, six hours per day on the internet. Over 70% of the interviewees in-tend to increase the use of online search engines to learn about healthier lifestyles, and to search regarding diseas-es and/or treatment options for their own beneit or for the beneit of third parties (family and friends).
Additionally, 69% airm that the internet has a very positive or positive impact on the relationship with their physicians. Ater an online research, 16% of the sample asked the physician to prescribe a speciic medication, and 10% asked the physician to change their prescrip-tions – of this total, 52% said that the physicians met their prescription requests. his data evidences not only that the access to healthcare information was extended with the democratization of internet access, but also – and as a result of it – that there was a change in the doctor-patient relationship. Physicians now have to deal with the pa-tients’ knowledge, which, until now, was something held only by healthcare professionals.
Aspden & Katz19 note that the great majority of the
users believe in the information value of the internet, considering it “highly important” for healthcare. Part of the users is suspicious about certain information; how-ever, the majority of them tend to believe in the content disseminated online. Pursuant to the authors, few people report having read reckless or very commercial infor-mation about healthcare on the internet. And those that have read allegedly misleading information are usually more critical, pursuant to the research. his data can be disturbing, considering that a good amount of informa-tion disseminated on the web is poor in quality, mistak-en, or with major conlict of interest. Misuse of content related to healthcare may, among other things, result in lethal consequences to internet users.
hese indings increase the importance that the inter-net has been gaining over recent years regarding online
healthcare research by the population. Some of these indings are even worthy of public debates involving the civil society, the state, and experts in the area, in order to establish healthcare-promoting actions on the web, initiatives capable of maintaining the user’s integrity and safety. Joint initiatives should also be prepared to resolve online conduct capable of causing harm to the popula-tion’s health.
In a study in which 800 Americans (sample represent-ing the population of the United States) were interviewed via telephone, 41% of the sample (328 individuals) had already searched for medical information on the internet – these searches were greater among women, white indi-viduals, and among those that believed themselves to be more skilled in internet browsing. he authors also noted that individuals that access health information usually do so multiple times.
Soares5 also mentions a study of the Health onNet
Foundation, carried out in 1998, which evidenced that women represent the majority of health searches on the internet.
Great part (73%) of the 328 Americans mentioned in the study of Aspden & Katz19 stated that they had
dis-cussed the information found on the internet with other people and/or with their physicians. Women, wealthier individuals, and those with greater internet skills showed a stronger tendency to discuss the information with oth-er people.
In the present study, the fact that 89% of the inter-viewees are women reairm the indings in the research of Aspden & Katz and Soares, that they represent the ma-jority of online searches for health. It was also observed that the present sample showed a strong tendency of sharing searched information, in addition to searching health topics on the internet several times a month.
In the present study, simple search engines (Google, Yahoo, etc.) were also pointed out as the most useful source of information regarding health issues, even over specialists’ opinion. he same phenomenon was observed when they indicated search engines as the irst source of health information.
Rice & Katz20 mentioned a study that focused on
in-ternet use by 220 physicians of New Jersey, in which three quarters of the interviewees agreed that physicians should recommend relevant websites (accurate and safe) to their patients. In this study, the authors postulate that the in-ternet already was, in the late 1990s, the largest source of health information both for users and physicians.
A systematic review by Masters1, who proposed to
Conversely, the demand of patients for such media is a factor that stimulates its use by physicians.
herefore, the internet also has a signiicant efect on the doctor-patient relationship. An increasing num-ber of physicians have being reporting a huge numnum-ber of patients that oten discuss information arising from the internet in their oices. In this review1, the author says
that 89% of physicians reported such an event.
Dart21 analyzed the socioeconomic variable and its
relationship with the use of the internet among 758 Aus-tralian individuals from three diferent communities (low income, average income, and college students). he internet proved to be a much more important source of health information for the college student sample. Low-income interviewees also demonstrated less access to the internet for medical information in comparison to those with average income and college students.
A cross sectional study conducted by Schwartz, et al.22
evaluated the use of the internet for health purposes in a sample of 1,289 checked-up patients in a family health care program in Detroit, USA. he study analyzed physi-cians’ perception on how their patients used the inter-net for health searches. Of the 1,289 participants, 65% reported to have access to the internet. Age, gender, race, and education were variables signiicantly correlated with access. Of the individuals with internet access, 74% had researched health information for themselves or family members.
Information regarding speciic diseases was the most frequently searched topic by the abovementioned sample, followed by information regarding medications, nutri-tion, and physical exercises. Patients determined the ac-curacy of the websites especially based on endorsement of governmental agencies or professional organizations. Personal evaluation of the reliability of the sources and understandability of the information were also important aspects to determine accuracy.
Almost 90% of that sample tried to verify the infor-mation obtained during a search for a health topic. Most of them also claimed to discuss website information with their physicians.
In the study by Schwartz et al.22, 92 physicians were
interviewed. Physicians tended to underestimate the pro-portion of their patients who used the internet to search for health information. Of this sample of 92 physicians, 36% said that at least one patient per week had brought health information derived from the internet, and 63% said they suggested a speciic website to their patients.
It is worth mentioning that, although the indiscrimi-nate use of information obtained on the internet may be harmful, this phenomenon also has a beneicial side. It allows more careful decisions by users or consumers, in addition to greater autonomy and freedom of choice.
Dart, et al.23 point out the major importance still
as-signed to physicians’ or specialists’ opinion. In the three study communities (lower class, middle class, and college students), the physician’s recommendation was deemed the main source of health information. However, there was a signiicant diference among the three communi-ties. he internet was the most used and/or deemed the most important source of health information among the college student population. Additionally, the lower class less frequently considered using the internet as a source of health information in the future.
Other usual sources of health information listed among the top four by all communities researched23
were: television and friends and family. However, the authors report lack of data and studies able to correlate socioeconomic variables with the use of the internet for health purposes.
This data shows the close relationship established among physicians, patients, and the use of the internet for health information, which will tend to be intensified in the coming years, given continuing growth of inter-net use.
Despite the importance of this relationship, few stud-ies in Brazil have proposed to analyze the proile of lay users and their mechanisms for searching health infor-mation on the internet. A better understanding of these patterns may be an important strategy to promote the public health of internet users.
In Brazil, in an attempt to qualify the health informa-tion available on the internet, initiatives such as FioCruz’s must be highlighted, with its Laiss (Internet, Health, and Society Laboratory – Laboratório Internet, Saúde e So-ciedade) Laboratory, which seeks to create mechanisms capable of evaluating the reliability of medical websites and the health information on the web. Also notewor-thy are the actions of the Regional Medical Council of the State of São Paulo (Conselho Regional de Medicina do Estado de São Paulo – CREMESP), which issued on February 20th, 2001 a resolution (No. 97) that provides
for the design, creation, maintenance, and professional activity on websites, pages, or portals about medicine and health on the internet.
right to demand from organizations and individuals re-sponsible for the websites: [1] transparency; [2] honesty; [3] quality; [4] informed consent; [5] privacy; [6] medi-cal ethics; and [7] responsibility and origin.
Outside of Brazil, among these initiatives, and per-haps with higher expressivity and pioneering spirit in the area, it is inevitable to highlight the work developed by the Health on the Net Foundation (HON), which since 1995 has promoted mechanisms capable of ensuring a more careful use the internet for health purposes24. he
entity exists to ensure that health information conveyed on the web follows critical ethical standards, by devel-oping a code of conduct (HONCode), which establishes rules to protect citizens from misleading health informa-tion. Some of these rules are: [1] the website should qual-ify who are the project owners and respect users’ privacy; [2] sources and data obtained from third parties should be mentioned; [3] details on the inancing of the website should be provided and advertisements should be clearly distinguished from the content.
Today, the HONCode is used by over 7,300 web-sites, amounting to more than 10 million pages and 102 countries.
here are few websites accredited by HON in Brazil. In a study of 100 websites containing information about dental cavities in children, Leite and Correia25 have
dem-onstrated that only 5.3% of the researched websites were accredited by HON.
HON also provides guidelines consisting of patient and information consumer advice, to guide users on how to safely take advantage of the internet when searching for health information. Some of these guidelines are: [1] governmental, hospital, and university websites, as well as those hosted by reputable institutions, are usually more reliable; [2] ask your physician for a list of reliable websites; [3] always use more than one website to com-pare information; [4] verify the source of the information provided; [5] check the person’s qualiication to provide information; [6] read the websites’ privacy policy to un-derstand how the data collected is used; [7] check wheth-er the website has any quality cwheth-ertiication seal; [8] always be careful, do not trust promises of miracle cures; [9] never take information or advice found on the internet as a replacement for an appointment with your health-care provider; [10] keep in mind your national laws and regulations when ordering a procedure or product on-line, and always check on the credibility and security of institutions selling products on the web.
Study data demonstrate the complexity of the issue of use of health information obtained on the internet and, consequently, the public agencies’ and/or non-governmental organizations’ responsibility related to the safety of this information, which not only changes the
doctor-patient relationship (oten compelling physicians to adopt a certain type of procedure “expected” by the patient due to information obtained on the web), but also become a risk to the health of individuals, who may look for improper treatments due to “diagnoses” performed via the internet.
CONCLUSION
he discussion presented indicates a health issue that de-serves attention not only from academia, given the insuf-icient scientiic knowledge on the problem, but more-over, that requires critical thought, on a societal basis, of what the state’s and specialized institutions’ role should be in ensuring citizens’ access to safe information. It is not about discussing censorship of certain websites or contents, but ensuring that those available are credible and unsuspected, ensuring safety to the patient and the user. It is, inally, a public health issue that deserves at-tention, involving governments and the civil society in a debate about the beneits and risks of using health infor-mation available on the internet.
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